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The nurse practitioner will see you now

As health reform kicks in, more of our health care is likely to come from non-M.D.s. Here's a guide to who's who.

Consumer Reports magazine: August 2013

For a country that has managed to outspend every other developed nation in the world on health care, the U.S. is oddly short on doctors, especially primary-care ones. We have about 30 primary-care physicians per 100,000 people, far fewer than any other industrialized country, including the United Kingdom (80), Germany (157), and France (159). You may have seen the headlines about U.S. physician shortages and how they’re poised to get even worse, with baby boomers entering retirement and millions of previously uninsured people about to enter the health care system as the Affordable Care Act kicks in. Who’s going to take care of all of those people?

Enter a growing population of nurses and other clinicians who’ve obtained advanced clinical and academic training (most hold a master’s or a doctoral degree) and are licensed to do many of the same things that physicians are, either as part of a team that includes a doctor or, in some cases, on their own or at a clinic in a retail pharmacy. Physicians and policy analysts often refer to them as “physician extenders” but they prefer to be called “advanced practice providers.”

The best-known alternative clinicians are nurse practitioners and physician assistants. They’ve worked routinely in hospitals, clinics, and other settings for a number of years but are now also working in doctors’ offices along with other non-M.D. clinicians with specialized training: dietitians, podiatrists, pharmacists, and mental-­health practitioners. And walk-in clinics in retail stores, whose usage has almost tripled since 2008, are usually staffed by nurse practitioners. (For details on types of providers, see the chart below.)

Can these providers improve your health care or save you money? We reviewed the evidence and spoke to researchers and clinicians to tackle important concerns about the burgeoning role of nonphysicians.

This report is the second in a series about the reforms afoot in how you will receive your medical care in the months and years ahead. The series is funded in part by a grant from Atlantic Philanthropies. Read the first installment, "A Doctor’s Office That’s All About You," to learn about patient-centered medical homes.

Questions of quality

To put it mildly, opinions vary on whether the proliferation of nonphysicians threatens the quality of health care.

Highly trained clinicians such as certified nurse midwives and nurse practitioners believe they should be allowed to practice independent of physician supervision, including prescribing medication on their own, as 16 states and the District of Columbia currently allow them to do. (The others require some level of physician involvement or supervision.) But physician groups such as the American Medical Association and American Academy of Family Physicians have lobbied on grounds of patient safety and quality of care against relaxing state “scope of practice” rules to allow nurse practitioners to do more without M.D. supervision.

Nursing advocates point to a 2010 report by the Institute of Medicine that recommended, among other things, that nurses should be free to “practice to the full extent of their education and training.”

“There’s an important element of professional pride and professional defensiveness on both sides,” says David Blumenthal, M.D., president of the Commonwealth Fund, a private groups that funds independent health-policy research.

Physician assistants by definition practice alongside doctors in hospitals or offices, so the question of their going it alone doesn’t arise. As for advanced practice nurses, a review by the Cochrane Collaboration, an independent international research group, found that they performed comparably to physicians on health outcomes and cost. And the nurses got higher grades on communication with patients seeking urgent attention.

And on an individual level, doctors and nonphysicians may be getting along better than their professional-society squabbles suggest.

“I personally see a nurse practitioner for my own gynecologic care,” says Christine Mackey, M.D., an internist at Allegheny General Hospital in Pittsburgh. “Since this is what she does all day, she has tremendous experience.”

“Physicians like and respect the nurse practitioners they work with, and vice versa,” says David Auerbach, Ph.D., a health economist at RAND, a nonprofit research organization. “A recent study confirmed that nurse practitioners do tend to defer certain types of complex patients or disease groups and diagnoses to physicians, and both N.P.s and physicians seem fine with that.”

Doug Hood, a physician assistant who specializes in stroke treatment in the neurology department at Yale-New Haven Hospital in Connecticut, describes his relationship with physicians as “absolutely harmonious.… A lot of people forget their particular levels, everyone works together. And it’s exciting to see, like a little MASH unit.”

Targeted training

Nurses’ training might also make them more qualified than doctors to handle aspects of care for certain common problems, such as wound care for diabetics and helping people manage high blood pressure and other chronic conditions, according to Melinda Abrams, the Commonwealth Fund’s vice president of patient-­centered coordinated care.

Other duties that primary-care doctors are currently saddled with might also be performed more competently and efficiently by practitioners with more targeted training. For instance, dietitians can be far better informed about nutrition than doctors because medical school tends to give the subject short shrift. A small survey of internal-medicine interns at a Pennsylvania hospital, published in the April 2008 Journal of the American College of Nutrition, found that only 14 percent believed physicians were adequately trained to do nutrition counseling.

A podiatrist, is probably more qualified for the critical task of caring for a diabetic patient’s feet. And a mental-health professional can provide counseling plus a more-nuanced evaluation of a patient’s need for, say, antidepressant medication or sleep drugs. People often receive those drugs from their primary-­care doctor without ever having to see a behavioral-health expert.

Of course, patients should have some say in who treats them, and a study published in the June 2013 edition of Health Affairs probed that question. When asked in general which type of provider they would prefer to get care from, consumers tend to pick the M.D. But given a theoretical choice of seeing the physician assistant or nurse practitioner today or a physician tomorrow for an acute condition such as a worsening cough, 60 percent chose the alternative provider.

Skyrocketing need

The changes are happening for several reasons. Physicians are projected to be in short supply, especially in primary-care specialties such as family practice, pediatrics, and general internal medicine. Those specialties have become increasingly less attractive to debt-laden medical-school graduates because they pay less than others.

Against that backdrop, the need for primary-­care services is taking off. A December 2008 government report estimated that demand will rise 22 percent by 2020 just to meet the demands of aging baby boomers, whereas supply would grow by only 14 percent, leaving a shortfall of about 50,000 doctors. And that estimate doesn’t take into account the previously uninsured patients who are about to enter the system because of health reform.

Some primary-care doctors have coped by turning their offices into “concierge” practices that charge patients an annual fee for easy access to appointments and the doctor’s time. But that doesn’t solve the problem of access for people who can’t afford the extra fee.

Related Topics

The health-reform law includes student-­loan breaks and other incentives to increase the supply of doctors. But that won’t be happening overnight. A medical education takes at least seven years and often longer. Even if more students graduate from medical schools, there is a limited supply of primary-care residency slots.

By contrast, “between 3 and 12 nurse practitioners can be educated for the price of educating 1 physician, and more quickly,” according to a 2011 article in the New England Journal of Medicine.

Alternative providers are filling some of the gap. An analysis by David Auerbach at RAND published in the July 2012 issue of the journal Medical Care projected that the number of nurse practitioners in the U.S. will roughly double from 128,000 in 2008 to 244,000 in 2025. The population of physician assistants is likewise expected to rise, from 83,600 in 2010 to 108,300 in 2020. That may be in part because the new health-­reform law provides stipends and tuition assistance to increase the number of physician assistants in the primary-care workforce.

So in theory at least, increasing reliance on non-M.D. providers is a win-win: more accessible care from nonphysicians, leaving more time for doctors to perform the complex diagnostic and treatment tasks that only they are trained to do.

The financial bottom line

Will the trend toward nonphysician providers save you money? It depends. Advanced ­practice nurses and physician assistants earn lower salaries than doctors, so it costs less for hospitals, clinics, and medical practices to employ them.

Nurse practitioners who practice alone get paid less on average than doctors do for the same services. And staffing retail clinics such as MinuteClinic (at certain CVS stores) and Take Care Clinic (Walgreens) with nurse practitioners rather than doctors is one reason those clinics are able to offer lower prices than doctor’s offices for basic services such as vaccines.

If you see a nurse practitioner in your doctor’s office for strep throat, you’ll probably be billed the same as if you saw the doctor. But in the long run, the increased use of alternative providers to coordinate care and provide preventive services such as nutrition advice could lower health care costs overall, resulting in slower-growing insurance premiums.

How to get the best care

Strategies include the following:

Become familiar with the kinds of health personnel and what each is most qualified for, using the chart below as a guide.

If someone you haven’t met before comes in to treat you, ask him to introduce himself if he doesn’t do so right away. Research shows that patients are more satisfied with their care when providers communicate who they and the other members of the team are.

If you’re shopping for a new primary-care practice, consider looking for a “medical home” that uses a team model in which physicians work side-by-side with nurse practitioners, physician assistants, or other types of clinicians rather than shouldering everything themselves.

If you feel uncertain about or unsatisfied with the care you’ve received from any provider, say so. And don’t hesitate to ask for a second opinion.

Who’s that in the white coat?

The professionals you see at doctors’ offices and hospitals nowadays are not necessarily physicians or nurses. Here’s a rundown of the varieties of health care practitioners:

Providers

What they do

Training/credentials/licensing

Advanced practice clinicians

Nurse practitioner (NP)

Assess patients; order and interpret diagnostic tests; diagnose and treat illness; prescribe medications, in
some states with doctor supervision.

RN plus master’s or doctoral degree
and advanced clinical training. National certification exam and state license.

Bachelor’s degree, followed by completion of an accredited P.A. program modeled on the medical-school curriculum (average length of program is 27 months, and
most grant master’s degrees). National certification exam and state license.

Specialized providers

Podiatrist (DPM), also known as podiatric physician or podiatric surgeon

Diagnose and treat conditions of the foot, ankle, and related structures of the leg; prescribe medications. May specialize
in surgery, sports medicine, wound care, pediatrics, or diabetic care.

Four years of podiatric medical school plus three years of hospital residency training. With advanced training and experience, can obtain board certification from the American Board of Podiatric Medicine or the American Board of Podiatric Surgery. State license.

Diagnose and treat mental illness and emotional and behavioral problems in individuals, couples, groups, and families.

Ph.D. and Psy.D.: doctoral degree.

Licensed clinical social worker and LPC: master’s or doctoral degree plus two or more years of supervised post-graduate experience. State licenses. Counselors
can also be certified by National Board
of Certified Counselors.

Dietitian (RD)

Food and nutrition counseling for general health, nutritional deficiencies, or disease management.

Bachelor’s degree with courses approved by professional organization, plus completion of an internship. National examination.

Pharmacist (Pharm.D.)

Dispense medication and immunizations, check for potential drug interactions, provide counseling on how
to take medication and limit side effects.

Doctor of pharmacy degree from an accredited school, plus internship. Two licensing exams, one covering pharmacy skills and knowledge and the other covering pharmacy law.

Physicians

M.D. (medical doctor)

Diagnose and treat illness
and injury, including surgery, examinations, testing, and prescribing medication.

Four years of medical school plus up to six years of residency training. Optional clinical fellowships and specialty certification. National licensing exams. State license.

DO (doctor of osteopathic medicine)

Practice as medical doctors
do in any specialty area. Some osteopaths also perform musculoskeletal manipulation.

Four years of osteopathic medical school, followed by medical or osteopathic residency training. Optional specialty certification. National licensing exam. State license.